VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Teachable Moments Preschool LLC
1915 Thomson Drive
Lynchburg, VA 24501
(434) 215-3148

Current Inspector: Rebecca Forestier (540) 309-2835

Inspection Date: Nov. 6, 2023

Complaint Related: No

Areas Reviewed:

8VAC20-780 ADMINISTRATION 8VAC20-780 STAFF QUALIFICATIONS AND TRAINING 8VAC20-780 PHYSICAL PLANT 8VAC20-780 STAFFING AND SUPERVISION 8VAC20-780 PROGRAMS. 8VAC20-780 SPECIAL CARE PROVISIONS AND EMERGENCIES 8VAC20-780 SPECIAL SERVICES 8VAC20-770 BACKGROUND CHECKS 20 ACCESS TO MINOR?S RECORDS 22.1 BACKGROUND CHECKS, CODE, CARBON MONOXIDE 63.2 CHILD ABUSE AND NEGLECT

Comments:

An unannounced monitoring inspection for a Conditional License was conducted on 11/06/2023. There were 44 children, ages 5 months-5 years, and 14 staff members present during the inspection. The inspector reviewed compliance in the areas of administration, staff qualifications and trainings, staff and supervision, physical plant, programs, emergencies, and nutrition. The children were observed in outdoor large motor play, learning activities, free choice activities, during lunch, and during rest time. A total of 5 children?s records, 5 staff records and 3 medications was reviewed. The inspector discussed the following with center staff: handwashing, linens, medication, and program administration. The inspector arrived for the inspection at 9:30 am and departed the center at 1:15 pm. Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the provider.

Violations:

Standard #:	22.1-289.035-B-4
Description:	Based on record review, the center failed to obtain a copy of a criminal history record check and a copy of a child abuse and neglect search from any state in which the individual has resided in the preceding five years. Evidence: The record for Staff 4 contained documentation that Staff 4 has resided outside of the state of Virginia within the preceding five years. The record for Staff 4 had a documented hire date of 08/21/2023. There was not a criminal history record check or a copy of a child abuse and neglect search from all of the states in which the individual had resided in the preceding five years available for review during the inspection.
Plan of Correction:	Will request the information. Moving forward the information will be requested if required.
Standard #:	8VAC20-770-60-B
Description:	Based on record review, the center failed to ensure that an employee must not be employed until the agency has the person?s completed sworn statement or affirmation. Evidence: 1. The record for Staff 1 contained a documented hire date of 08/21/2023. The sworn statement in the record for Staff 1 was dated 08/22/2023. 2. The record for Staff 2 contained a documented hire date of 08/21/2023. The sworn statement in the record for Staff 2 was dated 08/22/2023. 3. The record for Staff 3 contained a documented hire date of 08/21/2023. The sworn statement in the record for Staff 3 was dated 08/22/2023. 4. The record for Staff 4 contained a documented hire date of 08/21/2023. The sworn statement in the record for Staff 4 was dated 08/22/2023. 5. The record for Staff 5 contained a documented hire date of 08/21/2023. The sworn statement in the record for Staff 5 was dated 08/22/2023.
Plan of Correction:	Moving forward, sworn statements will be obtained during the interview process.
Standard #:	8VAC20-770-60-C-2
Description:	Based on record review, the center failed to obtain the findings from a search of the central registry within 30 days of employment. Evidence: 1. The record for Staff 3 contained a documented hire date of 08/21/2023. There were no findings from a search of the central registry for Staff 3 available for review during the 11/06/2023 inspection. Staff 3 was observed working during the inspection. 2. The record for Staff 4 contained a documented hire date of 08/21/2023. The search of the central registry for Staff 4 was dated 10/16/2023; the findings were not obtained within 30 days of employment. 3. The record for Staff 5 contained a documented hire date of 08/21/2023. There were no findings from a search of the central registry for Staff 5 available for review during the 11/06/2023 inspection. Staff 5 was observed working during the inspection.
Plan of Correction:	New central registries will be requested.
Standard #:	8VAC20-780-140-A
Description:	Based on staff interviews, the center failed to obtain a copy of the child?s physical examination before the child?s attendance or within 30 days after the first day of attendance. Evidence: The records for Child 1, 2, 3 and 4 did not contain physical examinations. Staff 6 verified that 08/21/2023 was the first date of attendance for all four of the children.
Plan of Correction:	Will get them from the parents.
Standard #:	8VAC20-780-150-B
Description:	Based on record review, the center failed to ensure that each immunization/physical examination report shall include the date of the physical examination and dates immunization were received and shall be signed by a physician, his designee, or an official of the local health department. Evidence: The immunization records in the record for Child 1, 2 and 3 were not signed by a physician, his designee, or an official of the local health department.
Plan of Correction:	Will get from parents.
Standard #:	8VAC20-780-160-A
Description:	Based on record review, the center failed to obtain documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children and that documentation shall have been completed within the last 30 calendar days of the date of employment. Evidence: 1. The record for Staff 1 contained a documented hire date of 08/21/2023. The tuberculosis screening was dated 10/13/2023; the screening was not completed prior to coming into contact with children. 2. The record for Staff 2 contained a documented hire date of 08/21/2023. The tuberculosis screening was dated 10/16/2023; the screening was not completed prior to coming into contact with children. 3. The record for Staff 3 contained a documented hire date of 08/21/2023. The tuberculosis screening was dated 10/19/2023; the screening was not completed prior to coming into contact with children. 4. The record for Staff 4 contained a documented hire date of 08/21/2023. The tuberculosis screening was dated 10/17/2023; the screening was not completed prior to coming into contact with children. 5. The record for Staff 5 contained a documented hire date of 08/21/2023. The tuberculosis screening was dated 10/12/2023; the screening was not completed prior to coming into contact with children.
Plan of Correction:	Moving forward, will get the screening prior to contact with children.
Standard #:	8VAC20-780-60-A
Description:	Based on record review, the center failed to ensure that the separate record for each child enrolled contains all of the elements as required by the standards. Evidence: 1. The record for Child 1 did not contain the following information: the home address for each parent who has custody; when applicable, work phone number and play of employment of each parent who has custody; the name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (there was no addressed provided for either designated person); written agreements between the parent and the center as required by the standards; and first date of attendance. 2. The record for Child 2 did not contain the following information: when applicable, work phone number and play of employment of each parent who has custody; name and phone number of the child?s physician; the name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (there were not designated people listed); names of person authorized to pick up the child; allergies and intolerances to medication or any other substances, and actions to take in an emergency situation; written agreements between the parent and the center as required by the standards; and first date of attendance. 3. The record for Child 3 did not contain the following information: the home address for each parent who has custody; when applicable, work phone number and play of employment of each parent who has custody; the name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (there was no addressed provided for either designated person); written agreements between the parent and the center as required by the standards; and first date of attendance. 4. The record for Child 4 did not contain the following information: the home address for each parent who has custody; when applicable, work phone number and play of employment of each parent who has custody; the name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (both designated people listed were the child?s parents); written agreements between the parent and the center as required by the standards; and first date of attendance. 5. The record for Child 5 did not contain the following information: the home address for each parent who has custody; when applicable, work phone number and play of employment of each parent who has custody; the name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (there was no addressed provided for either designated person); written agreements between the parent and the center as required by the standards; and first date of attendance.
Plan of Correction:	Will use the model forms.
Standard #:	8VAC20-780-70
Description:	Based on record review, the center failed to ensure that staff records contain all of the elements required by the standards. Evidence: 1. The record for Staff 1 did not contain the following information: job title; documentation that two or more references as to character and reputation as well as competency were checked before employment (the reference check did not include the results of the telephone reference check); and documentation that the individual possesses the education, certification, and experience required by the job title. 2. The record for Staff 2 did not contain the following information: job title; and documentation that two or more references as to character and reputation as well as competency were checked before employment (the reference check did not include the results of the telephone reference check). 3. The record for Staff 3 did not contain the following information: job title; and documentation that two or more references as to character and reputation as well as competency were checked before employment (the reference check did not include the results of the telephone reference check). 4. The record for Staff 4 did not contain the following information: job title; and documentation that the individual possesses the education, certification, and experience required by the job title. 5. The record for Staff 5 did not contain the following information: job title; and documentation that two or more references as to character and reputation as well as competency were checked before employment (the reference check did not include the results of the telephone reference check).
Plan of Correction:	Will get the information into the records.
Standard #:	8VAC20-780-340-F
Description:	Based on observations, the center failed to ensure that children under 10 years of age always shall be within actual sight and sound supervision of staff. Evidence: Child 5 was observed being taken out of their classroom to receive services from an outside organization. During that time Child 1 was not within actual sight and sound supervision of staff.
Plan of Correction:	Will get permission for services to be provided.
Standard #:	8VAC20-780-550-G
Description:	Based on document review, the center failed to ensure that the documentation of emergency evacuation drills contain all of the elements as required by the standards. Evidence: The documentation of the emergency evacuation drills did not contain the following information: identity of the person conducting the drill; the method used for notification of the drill; number of staff participating; any special conditions simulated; and problems encountered if any.
Plan of Correction:	Moving forward, will use the model form.